Patient Forms
OFFICE HOURS: Monday – Thursday: 8:00am to 5:00pm • Friday: 8:00am to 3:00pm
AFTER-HOURS CRISIS SUPPORT & VICTIM ASSISTANCE: 303-615-9911
Patient Forms
To expedite the check-in process for your Medical or Mental Health appointment, complete the appropriate patient forms prior to your appointment at the Health Center at Auraria. The Health Center staff will notify you of which forms to complete when you schedule your appointment. There may be additional forms that will be completed while you’re a patient at the Health Center at Auraria and will be completed at a later time.
Secure File Drop
Use this as directed by the Health Center at Auraria staff.
Secure File Drop
New Patient Packet
Complete this packet if this is your first appointment at the Health Center at Auraria.
New Patient Packet
Medical Records Release Form
Complete this form if you would like to request records for yourself or another facility. The Health Center at Auraria abides by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). All records are confidential and cannot be released to anyone without the patient’s written authorization except when the record is subpoenaed by court order or required by public health law.
Authorization for the Use of Disclosure of Protected Health Information
Observer Consent
Only complete this form if requested by a Health Center at Auraria provider or staff.
Patient Consent for Presence of Student Observer
Telehealth Treatment
Complete this form if you’re requesting a Telehealth appointment.
Consent for Telehealth Treatment
Mental Health Forms
ADHD Patient Packet
Complete this form if you’re scheduled for an ADD/ADHD Intake at the Health Center at Auraria.
ADHD Patient Packet
Adverse Childhood Experiences (ACE)
Complete this form if requested by your psychiatric provider.
ACE
ASRS
Complete this form if you’re scheduled for a Mental Health Intake at the Health Center at Auraria.
ASRS
DSM-5
Complete this form if you are scheduled for a Mental Health Intake at the Health Center at Auraria.
DSM-5
PHQ-9
Only complete this form if requested by a Health Center at Auraria provider.
PHQ-9
GAD-7
Only complete this form if requested by a Health Center at Auraria provider.
GAD-7
Medical Forms
MSU Denver Athlete Pre-participation Physical Evaluation History Form
Complete this form if you are an MSU Denver Athlete and have a preparticipation physical evaluation scheduled.
MSU Denver Athlete Pre-participation Physical Evaluation History Form
Controlled Substance Use Agreement
This document will be completed with your Health Center provider if prescribed medications that are classified as controlled substances.
Controlled Substance Use Agreement
Insomnia Packet
Complete this packet if you scheduled an Insomnia Intake appointment.
Insomnia Pre-Packet
Nutritional Counseling Intake Form
Complete this packet if you scheduled a Nutrition Counseling appointment.
Nutritional Counseling Intake Form
Smoking Cessation Questionnaire
Complete this form if scheduled for a Smoking Cessation intake appointment.
Smoking Cessation Questionnaire
Sport Concussion Assessment Tool (SCAT5)
This form is to be completed when instructed by a provider for a concussion assessment.
Sport Concussion Assessment Tool (SCAT5)
Stimulant Medication Agreement
This document will be completed with your Health Center provider if prescribed stimulant medications.
Stimulant Medication Agreement
Treatment of a Minor Parent/Guardian Consent Form
This form is used for parents or guardians to complete so medical or mental healthcare of their child who is under age 18 can take place.
Treatment of a Minor Parent/Guardian Consent Form
Letter Requests
Emotional Support Animal (Current Patients Only)
Complete this form if you are requesting a letter or form to be completed for an emotional support animal.
Emotional Support Animal Letter Request
Request for Accommodations for Medical Issues affecting Academics
Complete this form if you need a letter from your provider to document any medical or mental health diagnosis and/or treatment for accommodations, medical or academic withdrawals or SAP Appeals.
Medical Issues Affecting Academics Letter Request
Auraria Immunization Compliance Form
Auraria Campus Immunization Compliance Form
Complete this form if you are a new student to CCD, MSU Denver or CU Denver. For more information go to the Immunization Requirement.
Schedule an appointment
Please note there is a failed appointment fee of up to $50.00 for missed appointments or short notice cancellations (less than 24 hours).
